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Molina Bronze Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold Plan
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Accumulators †
Medical Deductible, Individual $6,400 Combined Med/Rx N/A $750 $3,300 $5,350 $2,925
Medical Deductible, Family $12,800 Combined Med/Rx N/A $1,500 $6,600 $10,700 $5,850
Rx Deductible, Individual Included in Medical deductible N/A N/A $400 (Ded applies to Tiers 3 and 4) $400 (Ded applies to Tiers 3 and 4) N/A
Rx Deductible, Family Included in Medical deductible N/A N/A $800 (Ded applies to Tiers 3 and 4) $800 (Ded applies to Tiers 3 and 4) N/A
OOPM, Individual $7,900 $1,400 $2,600 $6,300 $7,900 $5,000
OOPM, Family $15,800 $2,800 $5,200 $12,600 $15,800 $10,000
Emergency/Urgent Services
Emergency Room - Applies to facility charges only 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Urgent Care $75 $10 $20 $50 $50 $35
Outpatient Professional Services ‡
Office Visit — Preventive Care No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care $35 $0 $10 $20 $30 $10
Office Visit — Specialty Care $80 (after ded) ▲ $15 $30 $60 $75 $50
Office Visit — Other Practitioner Care $35 $0 $10 $20 $30 $10
Autism Spectrum Disorder Services $35 $0 $10 $20 $30 $10
Habilitative Services‡ 40% (after ded) ▲ $15 $30 $60 $75 $50
Rehabilitative Services‡ 40% (after ded) ▲ $15 $30 $60 $75 $50
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10
Substance Abuse Services $35 $0 $10 $20 $30 $10
Dental Services Related to Accidental Injury
 BENCHMARK INCLUDES;
BASIC DENTAL CARE, ORTHODONTIA &
 MAJOR DENTAL FOR CHILDREN
TMJ
40% (after ded) ▲ 10% 20% 30% 30% 20%
Family Planning No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Vision
BENCHMARK -NO LIMIT ON EYEGLASSES
 FOR CHILDREN OR ROUTINE CARE
No Charge No Charge No Charge No Charge No Charge No Charge
BENCHMARK
 Hearing Aids for Children
 For Dependent children under 18 years of age or under 21
years of age if still attending high school.
No Charge No Charge No Charge No Charge No Charge No Charge
Hearing aids in excess of $2500 per hearing impaired ear. 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35
Laboratory Tests $40 (after ded) ▲ $10 $10 $40 $40 $15
Mental / Behavioral Health / Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Outpatient Setting 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Inpatient Hospital Services
Medical / Surgical 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Maternity 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Inpatient Setting 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier-1: Lower-Cost Generic and Brand Name Drugs $20 $2 $5 $10 $20 $10
Tier-2: Preferred Generic and Brand Name Drugs 40% (after ded) ▲ $15 $30 $60 $60 $50
Tier-3: Non-Preferred Brand Name Drugs 50% (after ded) ▲ 20% 30% 40% (after ded) ▲ 40% (after ded) ▲ 30%
Tier-4: Generic and Brand Name Specialty Drugs 50% (after ded) ▲ 20% 30% 40% (after ded) ▲ 40% (after ded) ▲ 30%
Tier-5: Preventive Drugs No Charge No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (after ded) ▲ 10% 20% 30% 30% 20%
Home Infusion No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Home Healthcare No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 30% 30% 20%
Other Services
Dialysis Services (applies to facility charges only)
(This is outpatient cost sharing. For inpatient dialysis, IP hospital cost sharing applies)
$80 (after ded) ▲ $15 $30 $60 $75 $50
Nutritional Counceling-NM mandate
 Benchmark Changes: Specific obesity-related co-morbidities include,
but are not limited to:
  • Cardiomyophathy.
  • Congestive heart failure with an ejection fraction of 50% or less than predicted.
  • Documentation of previous myocardial infarction requiring hospitalization.
  • Documented Type 2 diabetes mellitus.
  • Uncontrolled/massive leg lymphedema.
  • Obstructive sleep apnea with baseline AHI or RDI of 15 or greater, or currently
    under treatment with a positive pressure device (CPAP, BiPAP, C-Flex, etc.).
  • Obesity related osteoarthritis of the lower extremities for which joint replacement
    surgery of the knee or ankle has been recommended.
  • Pickwickian syndrome or cor pulmonale.
$35 $0 $10 $20 $30 $10

Notes:​

Green highlighting indicates that no Ded applies

▲Ded Applies. Ded is waived, except where indicated

‡ Outpatient Habilitation & Rehabilitation configuration note: Member cost-share and visit limits shown apply in any place of service

§Mail-order Rx drugs for tiers 1, 2, 3, and 5. For mail-order Rx, up to a 90-day supply is provided at twice the 30-day retail cost-sharing amount.

BENCHMARK LIMITATIONS 20 VISITS PER YEAR

— 20 visits per year for spinal manipulation therapy

_ Acupuncture Limit of 20 visits per Calendar Year

Molina Bronze Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold Plan
Learn More Learn More Learn More Learn More Learn More Learn More
Accumulators †
Medical Deductible, Individual $6,400 Combined Med/Rx (Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) N/A $525 (Applies to OP Facility and IP services only) $2,500 (Applies to OP Facility and IP services only) $4,950 (Applies to OP Facility and IP services only) $3800 (Applies to OP Facility and IP services only)
Medical Deductible, Family $12,800 Combined Med/Rx (Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) N/A $1050 (Applies to OP Facility and IP services only) $5,000 (Applies to OP Facility and IP services only) $9,900 (Applies to OP Facility and IP services only) $7600 (Applies to OP Facility and IP services only)
Rx Deductible, Individual Included in Medical deductible N/A N/A $400 (Ded applies to Tiers 3 and 4) $400 (Ded applies to Tiers 3 and 4) N/A
Rx Deductible, Family Included in Medical deductible N/A N/A $800 (Ded applies to Tiers 3 and 4) $800 (Ded applies to Tiers 3 and 4) N/A
OOPM, Individual $7,350 $1,250 $2,450 $5,850 $7,350 $7,350
OOPM, Family $14,700 $2,500 $4,900 $11,700 $14,700 $14,700
Emergency/Urgent Services
Emergency Room - Applies to facility charges only $400 (after ded) ▲ $175 $250 (after ded) ▲ $400 (after ded) ▲ $400 (after ded) ▲ $300
Urgent Care $75 (after ded) ▲ $15 $30 $60 $75 $60
Outpatient Professional Services ‡
Office Visit — Preventive Care No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care $35 $0 $10 $20 $30 $10
Office Visit — Specialty Care $80 (after ded) ▲ $10 $30 $60 $75 $35
Office Visit — Other Practitioner Care $35 $0 $10 $20 $30 $10
Autism Spectrum Disorder Services $35 $0 $10 $20 $30 $10
Habilitative Services‡ 40% (after ded) ▲ $10 $30 $60 $75 $35
Rehabilitative Services‡ 40% (after ded) ▲ $10 $30 $60 $75 $35
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10
Substance Abuse Services $35 $0 $10 $20 $30 $10
Dental Services Related to Accidental Injury
 BENCHMARK INCLUDES;
BASIC DENTAL CARE, ORTHODONTIA &
 MAJOR DENTAL FOR CHILDREN
TMJ
40% (after ded) ▲ 10% 20% 40% 40% 20%
Family Planning No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Vision
BENCHMARK -NO LIMIT ON EYEGLASSES
 FOR CHILDREN OR ROUTINE CARE
No Charge No Charge No Charge No Charge No Charge No Charge
BENCHMARK
 Hearing Aids for Children
 For Dependent children under 18 years of age or under 21
years of age if still attending high school.
No Charge No Charge No Charge No Charge No Charge No Charge
Hearing aids in excess of $2500 per hearing impaired ear. 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35
Laboratory Tests $40 (after ded) ▲ $10 $10 $40 $40 $15
Mental / Behavioral Health / Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Inpatient Hospital Services
Medical / Surgical 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Maternity 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $20 $2 $5 $10 $20 $10
Tier 2 - Formulary Preferred Brand $60 (after ded) ▲ $15 $30 $60 $60 $50
Tier 3 - Formulary Non-Preferred Brand 50% (after ded) ▲ 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30%
Tier 4 - Formulary Specialty (Oral & Injectable) 50% (after ded) ▲ 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30%
Tier 5 - Formulary Preventive No Charge No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (after ded) ▲ 10% 20% 40% 40% 20%
Home Infusion No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Home Healthcare No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 40% 40% 20%
Other Services
Dialysis Services (applies to facility charges only)
(This is outpatient cost sharing. For inpatient dialysis, IP hospital cost sharing applies)
$80 (after ded) ▲ $10 $30 $60 $75 $35
Nutritional Counceling-NM mandate
 Benchmark Changes: Specific obesity-related co-morbidities include,
but are not limited to:
  • Cardiomyophathy.
  • Congestive heart failure with an ejection fraction of 50% or less than predicted.
  • Documentation of previous myocardial infarction requiring hospitalization.
  • Documented Type 2 diabetes mellitus.
  • Uncontrolled/massive leg lymphedema.
  • Obstructive sleep apnea with baseline AHI or RDI of 15 or greater, or currently
    under treatment with a positive pressure device (CPAP, BiPAP, C-Flex, etc.).
  • Obesity related osteoarthritis of the lower extremities for which joint replacement
    surgery of the knee or ankle has been recommended.
  • Pickwickian syndrome or cor pulmonale.
$35 $0 $10 $20 $30 $10

Notes:

As of 1/1/2018, cost sharing reduction for any prescription drugs obtained by You through the use of a discount card or coupon provided by a prescription drug manufacturer, or any other form of prescription drug third party cost-sharing assistance, will not apply toward any Deductible, or the Annual Out-of-Pocket Maximum under Your Plan.

Green highlighting indicates that no Ded applies

▲Ded Applies. Ded is waived, except where indicated

‡ Outpatient Habilitation & Rehabilitation configuration note: Member cost-share and visit limits shown apply in any place of service

§Mail-order Rx drugs available for tiers 1, 2, 3, and 5. For mail-order Rx, a 90-day supply is provided at twice the 30-day retail cost-sharing amount.

BENCHMARK LIMITATIONS 20 VISITS PER YEAR

— 20 visits per year for spinal manipulation therapy

_ Acupuncture Limit of 20 visits per Calendar Year

 

​Language Information

If you, or someone you’re helping, has questions about Molina Marketplace, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1 (888) 560-2043.

Información de idioma

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Molina Marketplace, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1 (888) 560-2043.

​Thông Tin Ngôn Ngữ

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Molina Marketplace, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-888-295-7651.

Sprachinformation

Falls Sie oder jemand, dem Sie helfen, Fragen zum [Molina Marketplace] haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-888-295-7651 an.

语言信息

如果您,或是您正在協助的對象,有關於[插入SBM項目的名稱 (Molina Marketplace)]方面的問題,您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員,請撥電話 [在此插入數字1-888-295-7651。

معلومات اللغة

إن كان لديك أو لدى شخص تساعده أسئلة بخصوص (Molina Marketplace)، فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ 7651-295-888-1 .

معلومات اللغة

إن كان لديك أو لدى شخص تساعده أسئلة بخصوص Molina Marketplace ، فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ 7651-295-888-1 .

언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Molina Marketplace 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는1-888-295-7651 로 전화하십시오.

Impormasyon sa Wika

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Molina Marketplace, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-888-295-7651 .

言語情報

ご本人様、またはお客様の身の回りの方でも、Molina Marketplace、についてご質問がございましたらご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場合、1-888-295-7651 までお電話ください。

Informations sur la langue

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Molina Marketplace, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-888-295-7651.

Informazioni sui servizi linguistici

Se tu o qualcuno che stai aiutando avete domande su Molina Marketplace, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-888-295-7651

Информация о языках

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Molina Marketplace, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-888-295-7651.

भाषा की जानकारी

>यदि आपके, या आप द्वारा सहायता किए जा रहे किसी व्यक्ति के Molina Marketplace के बारे में प्रश्न हैं, तो आपके पास अपनी भाषा में मुफ्त में सहायता और सूचना प्राप्त करने का अधिकार है। किसी दुभाषिए से बात करने के लिए, 1-888-295-7651 पर कॉल करें।

​ اطلاعات ترجمه و زبان

اگر شما، یا کسی که شما به او کمک میکنید ، سوال در مورد [Molina Marketplace] ، داشته باشید حق این را دارید که کمک و اطلاعات به زبان خود را به طور رایگان دریافت نمایید 1-888-295-7651. تماس حاصل نمایید.

ข้อมูลภาษา

หากคุณ หรือคนที่คุณกำลังช่วยเหลือมีคำถามเกี่ยวกับ Molina Marketplace คุณมีสิทธิที่จะได้รับความช่วยเหลือและข้อมูลในภาษาของคุณได้โดยไม่มีค่าใช้จ่าย พูดคุยกับล่าม โทร 1-888-295-7651

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